India saw a 4% spike in the number of cesarean section (C-section) deliveries between 2016 and 2021 despite a dip in pregnancy complications during the same time, according to a study carried out by researchers from IIT Madras.
Nearly one in two deliveries in private hospitals was a C-section, the study found. The odds of such a delivery were four times higher in private hospitals compared with public hospitals.
The study, undertaken by researchers from the department of humanities and social sciences at the institute, was published in BMC Pregnancy and Childbirth journal in August 2023. The researchers collated and analyzed data from the National Family Health Survey conducted in 2015-16 and 2019-21.
Reasons for C-section deliveries
A C-section delivery is a surgical procedure in which an incision is made in the mother’s belly to deliver the baby. The procedure is known to save the lives of both the mother and newborn in cases where there are pregnancy complications.
Dr Nirmala Chandrashekar, senior consultant, obstetrics and gynecology, Gleneagles Hospital, Kengeri, Bangalore, lists the following as the most common reasons for recommending a C-section:
- If there is fetal distress (where the fetal heartrate is dipping);
- If the labor is not progressing as expected;
- If the baby is too large;
- If the fetal head doesn’t descend; and
- If the mother has an underlying heart condition.
The study found that while C-section deliveries can be lifesaving when medically justified, they can cause adverse health outcomes if performed despite not been strictly necessary. Also, such surgical procedures add to expenditure and put a strain on already scarce public health resources, the researchers said.
C-section deliveries: What the study found
The major findings of the study were:
- The prevalence of C-sections across India increased from 17.2% to 21.5% in the five years leading up to 2021.
- The proportion of those with pregnancy complications decreased from 42.2% to 39.5% between 2016 and 2021.
- The odds of delivery by C-section were four times higher if the woman gave birth in a private hospital as compared with a public hospital.
- Women who were overweight and older (aged 35-49 years) were twice as likely to have C-sections as those who were not.
- In Chhattisgarh, women had a 10 times higher chance of delivering by C-section in a private hospital; in Tamil Nadu, they had a three times higher chance.
Commenting on the findings, Dr Chandrashekar says that in most of the cases she has handled clinically, it is the woman who opts for the C-section delivery, citing labour pain as the reason. She adds that the obstetrics’ team counsels the woman in labour as much as possible and explains that they also have the option of taking an epidural in normal delivery.
“We also explain the complications associated with C-section — such as the pain and discomfort the mother experiences, and infection of the wounds,” says Dr Chandrashekar. “We make the family aware that it would take longer to recover from a C-section procedure. Ultimately though, we must tailor the treatment to the needs of the patient.”
More women opting for C-section deliveries
The study attributed the increased rate of C-section deliveries to non-clinical factors such as women’s preferences, their socio-economic level and education, and risk-averse physicians practicing conservative medicine.
Researchers found that “better-educated women living in urban areas were more likely to deliver by C-section, suggesting that greater autonomy and better access to healthcare facilities play a role in the increase in prevalence of C-sections.”
Speaking about the findings of the study, Prof V R Muraleedharan, department of humanities and social sciences, IIT Madras, and one of the authors of the study, said in a statement, “A key finding was that the place of delivery (whether the delivery was in a public or a private facility) had the greatest impact on whether delivery was by C-section, implying that ‘clinical need’ factors were not necessarily the reason for surgical deliveries.”
The researchers added that in across India, the non-poor were more likely to opt for C-sections. Tamil Nadu was an exception, with the poor more likely to have C-sections in private hospitals.
The researchers, who also conducted a region-specific analysis, found that despite both pregnancy complications and high-risk fertility behavior being more prevalent in Chhattisgarh, it was Tamil Nadu that had the higher prevalence of C-sections. The pregnancy complications and high-risk fertility behavior they mentioned included factors that could cause adverse birth outcomes — such as the mother being younger than 18 years or older than 34 years, interval between births being less than 24 months or the child being the ‘fourth or greater’ in birth order.
While pointing out that the WHO-recommended rate for C-sections is between 10% and 15%, researchers recommended that the threshold levels for the surgical procedure should be applied cautiously, as several inter-category variations exist. Plus, in states at advanced levels of demographic transition, need factors for C-sections may be more prevalent.
“There is an alarmingly high proportion of poor women undergoing C-sections in the private sector in Tamil Nadu,” the study said. “This requires further analysis and corrective action in case some of these are clinically unnecessary.”
Takeaways
An IIT Madras study has found that the prevalence of C-section deliveries across India increased (from 17.2% to 21.5%) in the five years until 2021 — despite a dip in pregnancy complications. The researchers have attributed this to women’s preferences and their socio-economic level and education, among other reasons.
